Thursday, May 19, 2005

Being MD

Something happens when you've been a doctor for long enough. I never raise doctoring over other professions, or at least I hope I don't, and it is most likely true of many other professions as well. Once you've been a doctor for a few years (of residency), then it all comes pretty easily. You've worked out what you do in this and that situation. There are, obviously, an almost infinite combination of symptoms, medical problems, medications, and social structures. But you find yourself easily parsing it down into a few diagnostic tests and treatment options, which you then explore, hopefully with a smart and willing patient who wants to get better.

I've grown pretty good at what I do. I'm not very good at chess, but I have heard it said that masters of the game do not see simple moves. They have also passed beyond seeing lines of influence and power between different sections of the board. Instead, they take in the entire situation into one gestault, and then look for ways to make what they want to happen occur.

I don't know if I'm like that. But if you're my patient, I've taken in a gestault by the time you've gotten into your story. The data isn't as clean as on the chessboard. And my intervention may not make as much of an impact as the total control exerted in the game of kings. But in my mind, I've already identified you as a series of possible diagnoses.

I say this not to pay myself on the back. I say it to bring up what I want to post about.

I get about 20 journals every month. Each has about 200 pages, filled to the brim with adverts from Big Pharm. I skim through them. None of them has much impact on the way I practice. I haven't come across an article that's impacted me more than adding a medication in years.

And then I came across this New York Times article. And I'm so happy I did. It takes 3 patients (one millionaire architect, one blue collar, and one working poor) and tracks them through their heart attacks. It's terrible science. The n is 3. Bias abounds. Screening might exist. There is surely observer bias. There is no blind. There are no controls. And none of that shit matters to me. It's terrific. Well written, compeling, it gets things right that the media never gets right. It's as medically accurate as an ER in the Bronx. It takes complex truths and presents them to you as they are.

As you read it, ask yourselves the unsettling questions that you don't want to ask. Here are some (I'll provide answers at the end). 1. Why would a primary Polish speaking woman having an MI have to wait 2 hours in the waiting room? 2. Why did she not get the cath? 3. Why don't these people quit smoking, excercise, and eat right? 4. What will happen to these people?

The conclusions in the article speak for themselves. Read it and watch the segment.

Like I said, there are few things that change the way I do my job. But this has made me think deeply about it. It helps me understand some of the variables at work. At very least I can plan accordingly.

Probable Answers1. People who don't speak English don't know the key words, like 'chest pain' that get attention. A lack of quick, concise communication prevents diagnosis. She also went to the busy county ER, where there were 4 homeless people vomiting and having withdrawal seizures, shakes, and hallucinations in the hallway. There are 2 shootings that went ahead of her, a suicide bleeding all over the place, an OD in a coma, and a sickler crying in a crisis yet strangely refusing to drink water or juice, knowing that "Demerol. Demerol helps." I'm surprised a quiet, not bleeding, dizzy Polish speaking woman (who might have smelled of vodka) was seen within 2 hours.

2. She got an infection preventing it, her heart tissue died, and the acute event is now over. There is no sense in going in now.

3. One is tempted to say: because they are idiots. But the reasons are multifactorial. I'm not sure about all of them, but here are some: less education, more opportunity for bad food and less for good (that salad bar is expensive), smoking - a poor person's habit, less belief in the bad food = bad for you equation, comorbidities that prevent excercise.

4. We all die, some quicker, some slower. I don't need to tell you who's going to make it to 70 and who will not.